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Strategies for Appeals Success: Your Questions Answered

Posted Wednesday, June 18th, 2014 by Denise Junkin

Denials are expected to increase 100 to 200 percent during the initial phase of ICD-10, according to a February 2013 whitepaper titled “Readying Your Denials Management Strategy for ICD-10” published by the Healthcare Financial Management Association. Consequently, it’s important to have staff who are highly trained in handling denials and the appeals management processes in place now – well in advance of ICD-10 (you don’t want your practice to be learning new processes and tools amidst the massive ICD-10 transition). These skills, combined with a heavy dose of persistence, will go a long way.

Even the most persistent and exemplary staff can be faced with questions due to the complex nature of appeals. During our recent webinar, Strategies for Appeals Success, we covered many of the intricacies and details that can arise during the appeals process. Here are just a few:

When a denial happens as the result of a peer-to-peer physician review, should we insist on speaking with someone at the insurance company with the same credentials and specialty? What other course of action does our practice have?

Yes, practices can use state or federal utilization review laws to secure pre-certifications and demand specialty peer review of denials. Further, you may be able to cite the URAC utilization review standards if the carrier is URAC-certified. If the denial is in your practice’s specialty, claims appeals will likely focus on the demand for specialty and sub-specialty peer review protections since avoiding another denial will be particularly important.

If a payer makes coding changes to support new procedures that were recently assigned CPTs from the American Medical Association (AMA), how can we get additional written information on the coding change?

The AMA has three categories of CPT codes that can be changed or created. Category III, which addresses new procedures, releases approved codes on January 1 and July 1, and the code is effective six months after its release date. (Visit www.ama-assn.org/go/cpt for a list)

Practices have the right to request written disclosure of the justification for the coding change, especially if the plan is self-funded. ERISA, which governs most self-funded plans, has strict disclosure laws. The payer may not be recognizing you as the authorized representative. By providing this documentation, you can establish yourself as a qualified party to request any necessary documentation.

How do you request confirmation that a certified coder reviewed an appeal?

Use standard wording such as: “Please furnish the name and credentials of the certified coder who reviewed this claim and a copy of the coding criteria applied to the review, if any.” A good clearinghouse should provide a number of sample appeal letters related to this type of request.

To learn more, download a recording of the webinar, Strategies for Appeals Success. Do you have a comment or question about an appeal or denials management? Let us know in the comment section below.